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The functional regulator (FR-3) of Frtinkel

James A. McNamara, Jr., D.D.S., Ph.D.,* and Scott A. Huge** Dr. McNamara, Jr.
Ann Arbor, Mich., and Atlanta, Gg.

This article describes the construction of the FR-3 appliance classically used in cases of Class Ill malocclusion
characterized by maxillary skeletal retrusion. Included is a description of proper impression technique, construction
bite registration, preparation of the work models, and a complete description of the fabrication of the FR-3
appliance. Specific steps in the clinical management of this appliance are also presented. The cephalometric
records of three patients treated with the FR-3 appliance are then presented. (AM J ORTHOD 88: 409-424,
1985.)

Key words: Functional regulator, Frtinkel, Class III malocclusion, impressions, bite registration

THE FUNCTIONAL REGULATOR (FR-3) OF study that the forward development of the maxilla is
FRiiNKEL stimulated by the FR-3 appliance. However, a definitive
A method of functional jaw orthopedics that has study of the precise mechanism of action of this ap-
gained increased popularity in the United States is pred- pliance or a controlled clinical trial of the efficacy of
icated on the system of functional regulator appli- this type of functional regulator has not been published.
ances. developed by Professor Rolf Frtinkel of the Another use of the FR-3 has been suggested by Petit
German Democratic Republic. One of these appliances, in the treatment of severe Class III cases. Petit advocates
the FR-3,1A is used in the treatment of Class III mal- the use of heavy orthopedic forces generated by the
occlusions. This appliance has been used during the facial mask to achieve the initial correction of the mql-
deciduous, mixed, and early permanent dentition stages occlusion. Further, he suggests that an FR-3 may be
to correct Class III malocclusion characterized by max- used to retrain the maxillary anteroposterior correction
illary skeletal retrusion and not mandibular prognath- and to retrain the associated musculature.
ism.2*3 According to Frinkel,, the vestibular shields Eirew6 has stated that the FR-3 is an excellent re-
and upper labial pads function to counteract the forces training device and aid to muscular reeducation follow-
of the surrounding muscles that restrict forward max- ing surgical correction of mesiocclusion.
illary skeletal development and retrude maxillary tooth The purpose of this article is to describe the
position. FrPnkel* has also stated that the vestibular construction and clinical management of the Frgnkel
shields stand away from the alveolar process of the FR-3 appliance as it is currently used in the United
maxilla but fit closely in the mandible, thus stimulating States. Reports of three treated cases will also be
maxillary alveolar development and restricting mandib- presented.
ular alveolar development.
Fr8nke13reported a study of 74 severe Class III cases PARTS OF THE APPLIANCE
treated with the FR-3, comparing these casesto 58 Class The FR-3 (Fig. 1) is composed of wire and acrylic.
II cases treated with the FR-1 appliance. He noted As with the FR-2 appliance, the base of operation is
greater forward movement of maxillary landmarks in the buccal and labial vestibule. The FR-3 is less com-
the Class III cases than in the Class II cases. He also plicated than the FR-2 appliance in that there is no
stated that the changes in maxillary position in the Class lingual shield, which is necessary in the FR-2 to prompt
II cases were minimal in comparison to what would a forward repositioning of the lower jaw.
normally occur during growth. He concluded from this There are four acrylic parts of the FR-3: two ves-
tibular shields and two upper labial pads (Fig. 1, A and
The preparation of this manuscript was supported in part by United States
B). The vestibular shields extend from the depth of the
Public Health Service Grant DE-03610. mandibular vestibule to the height of the maxillary ves-
*Professor of Dentistry (Orthodontics), Professor of Anatomy and Cell Biology, tibule. These shields act to remove the restrictive forces
and Research Scientist, Center for Human Growth and Development. The
University of Michigan.
created by the buccinator and associated facial muscles
**Clinical Instructor, Department of Orthodontics, Emory University, and Spe- against the lateral surfaces of the alveoli and the as-
cialty Appliance Works. sociated buccal dentition.
409
410 McNamara and Huge

Fig. 2. The proposed method of action of the FR-3 appliance.


The distracting forces of the upper lip are removed from the
maxilla by the upper labial pads. The force of the upper lip is
transmitted through the appliance to the mandible because of
the close fit of the appliance to that arch (after Friinkel).

the associated soft tissue may be transmitted through


the appliance to the mandible. Presently there are no
studies to indicate that the force generated by the ap-
pliance is sufficient to lead to a significant retardation
of mandibular growth. However, the three case reports
presented in this article indicate that the vector of man-
dibular growth may be redirected vertically.
Fig. 1. Schematic illustration of the FR-3 appliance of Frankel. There are five wire components in the Frankel FR-
A, Frontal view. B, Lateral view. The wire components of the
appliance are (A), Upper labial wires (three-wire design), (S),
3, some of which are also found in the FR-2. The upper
Upper lingual wire, (C), Lower labial support wire, (D), Upper labial pads are connected to the vestibuiar shields by a
occlusal rest, (E), Palatal wire, and (f), Lower occlusal rest. support wire that may be a single continuous wire or a
series of three adjacent wires (Fig. 1). The lower as-
pects of the vestibular shield are connected by a lower
The upper labial pads that lie in the labial vestibule labial wire that rests against the labial surface of the
above the upper incisors (Fig. 1) function to eliminate lower incisors. On the lingual surface, an upper lingual
the restrictive pressure of the upper lip on the under- wire (Fig. 3, A) originates in the vestibular shield,
developed maxilla. The upper labial pads are larger and traverses the interocclusal space, and rests against the
more extended than the corresponding lower pads of cingula of the upper incisors. In contrast to the FR-2,
the FR-2 and are more easily tolerated by the patient the upper lingual wire does not lie between the canine
despite this greater extent. According to FrHnkel,2,3 and first deciduous molar (or first premolar), but rather
these pads also provide a stretching of the adjacent lies in the interocclusal space between the upper and
periosteum, stimulating bone apposition on the labial lower dentalarches (Fig. 4).
alveolar surface. This has not been verified by others. The palatal wire (Fig. 3, A) originates in the ves-
The upper labial pads of the FR-3 are in an inverted tibular shields and traverses the palate. In contrast to
tear-drop shape in sagittal view (Fig. 2). They should the FR-2 in which the palatal wire lies between the
lie in the height of the vestibular sulcus parallel to the second deciduous molar and the first permanent molar,
contour of the alveolus. The force of the upper lip is the palatal wire crosses the palate behind the last molar
transferred by the upper labial pads to the vestibular present (Fig. 4). Thus, the maxilla and the maxillary
shields. Since the vestibular shields lie in close ap- dentition are not restricted in their forward movement
proximation to the mandibular alveolus, the force of by the wires of the appliance.
Volume 88
Functional regulator (FR-3) of FrZinkel 411
Number 5

There are two pairs of occlusal rests in the molar


region, one of which is optional. A lower occlusal rest
(Fig. 3, B) originates in the vestibular shield, makes a
gentle right angle bend along the central groove of the
lower first molar, and then extends again back into the
vestibular shield posteriorly. The purpose of this wire
is to prevent the eruption of the lower first molar as is
advocated by Harvold in the treatment of Class III
malocclusions. Eirew6 recommends that the mandibular
occlusal rest be constructed to cover all erupted or even
partially erupted mandibular molars.
The maxillary occlusal rest (Fig. 3, A) is necessary
only in cases of anterior crossbite. This wire should be
placed so that only enough vertical opening is achieved
to allow for the correction of the anterior crossbite. As
soon as the crossbite has been corrected, the upper
occlusal rest should be removed from the appliance to
minimize bite opening. The upper occlusal rest origi-
nates in the posterior aspect of the vestibular shield,
traverses the central groove of the upper first molar,
and then recurves back on itself. The upper occlusal
rest is designed in this manner so as not to restrict the
forward movement of the maxilla during functional
therapy.
Impression technique
As in any appliance that is primarily tissue-borne,
Fig. 3. Schematic view of the FR-3. A, Maxillary view with upper
successful Fr&nkel treatment depends upon the fit and lingual wire (s), lower labial support wire (C), upper occlusal
comfort of the appliance. Thus, it is imperative that a rest (o), and palatal wire (El. B, Mandibular view with upper
proper impression-taking technique be used. An ac- labial support wire (Al, palatal wire (E), and lower occlusal rest
curate reproduction of the dentition and the associated fF).
soft tissue is essential for proper appliance fabrication.
The extension of the buccal vestibule must be clearly
defined and the upper limits of the anterior maxillary
region must be clearly discernible.
During the past few years, a number of different
types of impression trays have been used. The type of
tray that we have found to be most successful is a
thermal sensitive acrylic tray that is softened in hot L&al wire
water, placed in the mouth, and molded to the config-
uration of the hard- and soft-tissue structures. In ad- Fig. 4. Position of palatal and lingual wires of the FR-3 appliance
(after FrankelI).
dition, we advocate the use of a molding compound in
the upper anterior region to provide additional extension
of the tray into the anterior vestibule. Compound can of the vertical and lateral distortion of the soft tissue
also be applied in the posterosuperior aspects of the produced by these types of trays.
tray to provide additional definition in the tuberosity
region. A custom tray that is fabricated for the indi- Construction bite
vidual case can also be used. As with the FR-2 appliance, a proper construction
It is extremely important in the fabrication of the bite is essential to appliance fabrication. A horseshoe
FR-3 that the impressions not be overextended or un- wafer of medium hard wax is used to orient the upper
derextended. The use of overextended trays including and lower dental arches in all three planes of space
stock Styrofoam trays is usually contraindicated because (horizontal, transverse, and vertical). Any arbitrary ad-
412 McNamara and Huge Am. J. Orthod.
Novembrr 1985

FM. 5. Preparation of work models and oencil outline for future vestibular shields and upper labial
pads. A, Lateral view. 8, Frontal view.

justments in work-model orientation during appliance and compound extension have been used to obtain the
fabrication can lead to an appliance that does not fit impression. This area is carved to allow proper place-
properly. ment of the upper labial pads (Fig. 5).
The bite registration is taken with the patients man- When the preparation of the work models is com-
dible in the mast comfortably retruded position. It is pleted, the wax bite is inserted and the posterior surfaces
necessary to allow 1 to 2 mm of interocclusal space in of the model are checked to ascertain that the backs of
the molar region for the construction of the lower and, the models are flush. This is an important step because
when necessary, upper occlusal rests. A wide open-bite it will allow the laboratory to check the wax bite when
registration should be avoided. In cases with an anterior the work models are received and it will also allow the
open bite, only 1 mm of vertical bite-opening in the clinician to check the bite registration when the appli-
posterior region is necessary. ance is returned from the laboratory.

Preparation of work models Prescription sheet


After the impressions have been taken, they are Usually there is little variation with regard to the
poured in either hard plaster or stone with a base suf- prescription for the FR-3 laboratory fabrication. A stan-
ficient to allow adequate trimming (Fig. 5). It is im- dard amount of wax relief is ordinarily used. Three
portant that an adequate base be present to allow for millimeters of wax relief is prescribed for the maxillary
carving, particularly in the upper anterior region. The alveolar area and the upper labial pad region; there is
models are trimmed with the wax bite in place; the no wax relief prescribed for the mandibular model.
backs of the models should be trimmed flush with each Specific alterations in the amount of wax relief in the
other. maxillary region can be indicated on the prescription
The first step in carving the work models is to re- sheet. Little variation in wax relief is prescribed in the
move excess flash and bubbles. The models should then mandibular vestibule since this area cannot tolerate sig-
be carved to help define the borders of the eventual nificant lateral extension of the appliance.
vestibular shields. In most instances it is not necessary In contrast to the FR-2 appliance precription, notch-
to carve the mandibular region, particularly if the lower ing of the maxillary teeth is not required for the FR-3.
border of the mandibular sulcus has been defined by Every effort is made to allow forward movement of the
the impression. However, it is sometimes necessary to maxilla during treatment.
carve the upper vestibular region in the area of the
tuberosity to allow for a better definition of the superior APPLIANCE FABRICATiON
extent of the vestibular shield. In addition, it is some- Mounting the work models
times necessary to define the areas of muscle attachment The work models are checked by the technician after
that usually appear adjacent to the upper first premolar they have reached the laboratory. Any obvious distor-
(Fig. 5). tion or problems with the wax bite should be noted. If
It is almost always necessary to define the position the models and the wax bite are satisfactory, the work
of the upper labial pads, even when a close-fitting tray models are then mounted in a fixator model holder with
Volume 88 Functional regulator (FR-3) of Friinkel 413
Number 5

Fig. 6. Placement of wax relief for the vestibular shields and the upper labial pads. A, Lateral view.
6, Oblique lateral view. C, Frontal view. D, Oblique maxillary view. E, Maxillary occlusal view. F,
Mandibular view. Note the lack of wax relief in the mandibular arch.

the wax bite still in place. After the mounting stone Application of wax relief
has hardened, the wax bite is removed and the amount First, the outlines of the vestibular shields and upper
of interocclusal space is checked for adequate, but not labial pads are drawn on the model with a pencil (Fig.
excessive, separation of the models to allow for con- 5). These outlines are used as a guide in the placement
struction of the appliance. of the wax. The models are then separated and wax
Flg. 7. Completed wax relief and wire work for the FR-3 appliance. A, Lateral view. 6, Frontal view.
C, Maxillary view. D, Maxillary oblique view. E, Mandibular view. This appliance does not include an
upper occlusal rest.

relief is applied in the posterior and upper anterior re- placed on the mandibular cast, although the gingival
gions of the maxillary dental cast as prescribed by the margins are carefully waxed out in the region of the
clinician (Fig. 6). Additional wax is then applied in vestibular shields to prevent the occurrence of gingival
the dental area to establish a smooth contour on the irritation and also to save time in polishing the inside
lingual side of the vestibular shield. No wax relief is of the shields.
Volume 88 Functional regulator (FR-3) of Friinkel 415
Number 5

Fig. 8. The relationship of the upper occlusal rest to the lower occlusal rest. A, Maxillary view. B,
Maxillary oblique view.

Wire fabrication shield so that the activation produces a forward and


The lower labial support The lower labial
wire. upward movement of the labial shields.6
support wire is formed from a single piece of 0.040- The upper lingual wire. The upper lingual wire is
inch round stainless steel wire. It originates in the area made of 0.028-inch or 0.032-inch stainless steel. It
of the future vestibular shield and curves gently down- originates in the vestibular shield and traverses the in-
ward first and then upward toward the lower incisors terocclusal area between the upper canine and the upper
(Fig. 7). It crosses the lower incisors along the gingival first deciduous molar (Figs. 3, 4, and 7). It does not
one third of the facial surface. The lower labial wire is touch the maxillary or mandibular dentition. The wire
held in position by sticky wax in the central incisor then recurves along the lingual surface of the upper
area (Fig. 7, B). incisors at the level of the cingula. The upper lingual
The upper labial support wire. The upper labial wire can be used to stabilize the incisors during
support wire connects the upper labial pads one to an- treatment.
other and to the vestibular shields (Fig. 7). This wire Wire bends are made gradual rather than sharp to
exits the vestibular shields along the upper anterior mar- avoid breakage. This is especially important at the point
gin in a slightly upward direction. The wire then curves where the upper lingual wire enters the buccal shield.
further upward to the location of the upper labial pads In cases where the upper lingual wire is fractured re-
and then downward to accommodate the position of the peatedly, the use of separate crossed wires covered by
labial frenum. This wire is constructed of 0.040-inch a short sleeve may be considered.6
round stainless steel wire and is fastened to the model Palatal wire. The 0.040-inch stainless steel palatal
with sticky wax just above the lower labial frenum wire originates in the posterior aspect of the vestibular
superior to the upper incisor before the acrylic fabri- shield and traverses the palate posterior to the terminal
cation of the labial pads (Fig. 7, B). molar (Figs. 3, 4, and 7). The palate wire is kept
It must be stressed that the part of the upper labial slightly off the palatal mucosa to prevent irritation. The
support wire inside the vestibular shield must remain eruption of another molar posterior to the palatal wire
straight. If this wire is bent or curved, it will not move will usually result in a fracture of the wire. During the
during the activation of the upper labial pads (to be repair or fabrication of a new appliance, the wire should
covered later). The wire should also be tilted in the be placed behind the erupting tooth.
416 McNamara and Huge

Fig. 9. Finished functional regulator (F&3). A, Lateral view. 6, Frontal view. C, Maxillary occlusal
view. D, Maxillary oblique view. E, Mandibular view. This appliance does not include an upper occlusal
rest.

The lower occlusal rest wire. The lower occlusal dibular second deciduous molar and first permanent
rest wire (Fig. 7) originates in the lower posterior aspect molar. It then curves posteriorly to traverse the central
of the vestibular shield. It curves medially and then groove of the lower first molar and then recurves lat-
anteriorly at the interproximal surface between the man- erally to insert once again into the vestibular shield.
Volume 88 Functional regulator (FR-3) of Friinkel 417
Number 5

This wire is made from 0.030-inch round stainless steel.


,I,.;)\,
::;..I
;,:
0 0.
The upper occlusal rest wire. As mentioned pre-
viously, the upper occlusal rest wire is only used when
it is necessary to open the bite anteriorly to allow cor-
rection of an anterior crossbite. A doubleback design
of 0.036-inch stainless steel is used (Figs. 3 and 8). It
originates in the posterior aspect of the vestibular
shield, passes anteriorly, and then recurves along the
central groove of the upper first molar. If used, this
wire is eliminated from the appliance once the anterior
crossbite has been corrected.
4qA. 6.
Fig. 10. A, Proper fit of the upper labial pad of the FR-3 appli-
ance. The distance from the linqual surface of the upper labial
Acrylic fabrication pad to the maxillary alveolus is approximately 3 mm. B, Im-
The next step in the fabrication of the FR-3 is the proper fit of the upper labial pad. Pad is too vertical and placed
too low in the maxillary vestibule (after FrBnkel).
application of the acrylic to form the vestibular shield
and the upper labial pads. In preparation the upper and
lower models are locked together in the articulator. The distortion from the original fit should be noted. The
heels of the models are checked once again to make extensions of the acrylic borders should be checked on
sure that the bite is still accurate. the models for accuracy; the fit of the lower labial wire,
The acrylic is applied with alternate applications of the upper labial pads (Fig. lo), and the occlusal rest
monomer and polymer. During this process the name should also be examined. The final adjustments of the
of the patient and date of appliance placement are typed appliance, of course, are made by the clinician at the
on a small piece of onionskin paper and placed in the time of delivery of the appliance to the patient.
acrylic. After the acrylic has hardened slightly, the ves-
tibular shields and the upper labial pads can be trimmed DELIVERY OF APPLIANCE
to approximate the final size and shape; the acrylic is At the time of appliance delivery, the clinician
then cured under pressure for 15 minutes. checks to see that the contours of the acrylic parts of
After curing, the appliance is removed from the the appliance extend well into the vestibule and gently
work models and placed in an ice bath to harden blend into the alveolar process. Since there is no for-
the wax and facilitate its removal. All wires should ward repositioning of the mandible, little adjustment is
be gently pried free before the appliance is separated needed at time of delivery.
from the models. This is done to avoid distortion of The patient should be instructed that this appliance
the wires. is a full-time appliance and that it will eventually be
worn at all times except during eating, dental hygiene,
Trimming the appliance playing contact sports, language lessons, or playing
After the appliance has been removed from the work musical instruments that are held in the mouth. The
model, it is roughly trimmed with a sandpaper arbor. patient is instructed to read aloud for one-half hour per
First, the rough outlines of the upper labial pads and day until normal speech can be accomplished while
the vestibular shields are formed and smoothed. The wearing the appliance.
thickness of the vestibular shields is also reduced to a During the break-in period, the patient is instructed
uniform 2.0 to 2.5 mm in the same manner. to wear the appliance on an increasing basis. It is usually
A handpiece and a small burr are used to fine-trim recommended that the appliance be worn for a few
around the wires at the edges of the appliance. Con- hours a day for the first few weeks, then gradually
siderable care is to be taken during this procedure be- increasing wear time until the patient wears it full time.
cause the wires entering the vestibular shield can be Since there is little change in mandibular position pro-
greatly weakened if they are nicked or distorted in any duced by the appliance, the occurrence of sore spots
way during the trimming process. Then the acrylic parts and other clinical problems are less frequent than when
of the appliance are pumiced and polished on a rag the FR-2 appliance is used.
wheel. All edges of the appliance must be smooth to
avoid irritation and gingival stripping. Activating the appliance
After the appliance has been worn on a full-time
Evaluation of the finished appliance basis for 3 or 4 months, the distance between the upper
After the polishing has been completed, the appli- labial pads and the underlying alveolus will decrease.
ance is placed back on the work models (Fig. 9); any Thus, activation of the appliance is necessary to con-
418 McNamara and Huge Am. J. Orrhod.
November 1985

d
9-7

Fig. 11. Case I cephalometric tracings. A, Tracing of initial lateral cephalogram. B, Tracing of
ceihalogram taken 15 months later.

tinue treatment. A crosscut fissure burr is used in a low- an idealized mixed-dentition patient, Point A lies on the na-
speed dental handpiece to free the ends of the labial- sion perpendicular).0 The effective midfacial length (mea-
pad support wires. Enough acrylic is removed around sured from condyhon to Point A) was 78 mm. In a balanced
face the corresponding effective mandibular length is 95 to
the end of this wire to allow anterior advancement of
98 mm. I0Since the effective mandibular length in this patient
the wire and maxillary labial pads. The lingual surface was 111 mm, it can be assumedthat the patient had a 13 to
of the upper labial pads are kept 3 mm away from the 16-mm imbalance in the effective lengths of the upper and
underlying alveolus throughout treatment. After the up- lower jaws.
per labial-pad adjustment has been checked for patient The patients lower anterior facial height was greater than
comfort, the holes in the vestibular shields are refilled normal (approximately 5 mm over expectedvalues).The man-
with acrylic to secure the labial-pad support wire. In dibular plane angle was within normal limits (27), as was
cases of severe maxillary skeletal retrusion, more than the facial axis angle (0). The maxillary central incisors were
one advancement of the maxillary labial pads may be in a normal position relative to the maxilla with the facial
necessary. surfaceof the incisors5 mm ahead of a line dropped vertically
through Point A (ideal 4 to 6 mm).OThe mandibular central
CASEREPORTS incisors were 5 mm ahead of the A-pogonion line (ideal 1 to
3 mm).
In the next section of this article, the skeletal and
dental adaptations observed in three patients treated Treatment progress
with the functional regulator appliance will be de- The impressions and construction bite for the FR-3 ap-
scribed. Each patient presented with a different mor- pliance were carried out in accordancewith the methods pre-
phologic configurationat the beginning of treatment. viously outlined in this article. The bite registration was taken
in the most comfortably retruded mandibular position. With
this bite registration, the patient could attain an end-to-end
CASE I incisal relationship. The appliance was worn on a full-time
This patient, an &year-old boy, presented with a Class basis (approximately 20 hours per day) for a period of 12
III malocclusion characterizedby maxillary skeletalretrusion months.
and an anterior crossbite.
The initial lateral head film (Fig. 11, A) was analyzed Analysis of t t=sammt results
according to the cephalometric analysisof the senior author. As can be observed in the cephalometric tracing of the
The maxilla was located posteriorly relative to the cranial lateral head film (Fig. 11, B) taken 1 year 3 months after the
base. Point A was 3 mm behind the nasion perpendicular (in initial head film (Fig. 11, A), both skeletal and dental ad-
Volume 88 Function& regulator (FR-3) of Friinkel 419
Number 5

Flg. 11. (Contd). Ctise I cephalometric tracings. C, Sciperimposition of the tracings in A and B along
the basion-nasion line at the ptetygomaxillary fissure. D, Mandibular superimposition on the internal
structures. E, Msuiillary superimposition on internal structures. F, Maxillary displacement. Superim-
position is along the basion-nasion line at nasion.

aptations were observed. During 1 year of treatment, there anterior facial height (approximately 1 mm per year increase
was a 3-mm increase in the length of the midface-about in this dimension is expected). The chin point became more
twice as much as would be normally expected in a patient of retrusive relative to the nasion perpendicular.
this age. The maxilla was displaced 1 mm in an anterior Adaptations in the various regions of the craniofacial
direction relative to Point A. complex were analyzed according to the four-point super-
Mandibular length also increased by 3 mm (2 to 3 mm imposition of Ricketts.I
is usually observed in untreated persons), as did the lower Cranial base superimposition (Fig. 11, C). Superimpo-
Am. J. Orthod.
4%) McNamara and Huge
November 1985

Flg. 12. Case II cephalometric tracings. A, Tracing of initial cephabgram. B, Tracing of cephabgram
taken 2% years later.

sition along the basion-nasionline at its intersection with the and slightly downward direction with even greater movement
pterygomaxillary fissure indicated that the mandible de- observed in the maxillary dentition. The mandible was re-
scendedvertically with no changein anteroposteriorposition. directed vertically in its vector of growth with little evidence
The maxilla moved in a downward and forward direction of anteroposterior repositioning of the chin.
approximately 3 mm. The position of the lower incisor was
CASE II
relatively unchanged, although the upper incisor moved into
a more forward position, eliminating the anterior crossbite. The patient, a girl aged 7 years 6 months, had a Class
A forward and slight downward movement of the upper molar III malocclusion characterizedby a Class 111molar relation-
was also noted. ship and an anterior crossbite. In comparison to the patient
Mandibular superimposition (Fig. 11, D). Superimpo in CaseI, this patient did not have maxillary skeletalretrusion
sition on the internal structuresof the mandible (for example, at the beginning of treatment. The evaluation of the initial
the inferior alveolar canal and the lingual aspect of the sym- head film (Fig. 12, A) indicated the presenceof a normally
physis) indicated that mandibular growth was reoriented in a related maxilla relative to cranial basestructures.Point A was
vertical direction with some areasof resorption at the inferior 2 mm ahead of the nasion perpendicular. A midfacial length
aspect of the gonial angle. The lower molar and the lower of 85 mm should correspondto a mandibular length of 105
incisor erupted vertically with no anteroposteriormovement. to I08 mm, indicating that the mandible of this patient was
Maxillary superimposition (Fig. 11, E). Superimposition normally related to the midface.
on the internal structures of the maxilla showed a forward A patient with an 85mm midfacial length should also
and slight downward movement of the upper incisorsand the have a lower anterior facial height of 60 to 62 mm. This
upper molars. Some changes in the external contour of the patient had a 7-mm deficiency in lower anterior facial height.
maxilla were also evident. The mandibular plane angle was normal (23) and the facial
Maxillary displacement (Fig. 11, F). Superimposition axis angle of 8 indicated a horizontal vector of growth (nor-
along the basion-nasionline at nasion showed that the maxilla mal is 0).
moved slightly forward during treatment, an adaptation that The upper incisor was normally positioned (5 mm ahead
presumably would not have occurred without treatment. Rel- of a vertical line dropped through Point A) and the lower
ative to nasion, the upper incisors moved in a downward and incisors were slightly protrusive (4 mm ahead of the A-po-
forward direction, as did the upper molars. gonion line).
Summary Treatment progress
This patient demonstrated both skeletal and dental ad- The FR-3 appliance was constructed in accordancewith
aptations during treatment. The maxilla moved in a forward the methods outlined in this article. A second appliance was
Volume 88 Functional regulator (FR-3) of Friinkel 421
Number 5

? II II
i I
-7-6 10-O
---
I 1
I I
J! !

Fig.12 (Contd). Case ii caphaiometric tracings. C, Superimposition of the cephaiograms in A and B


along the basion-nasion line at the pterygomaxiiiaty fissure. D, Mandibular superimposition along
internal structures. E, Maxillary superimposition along internal structures. F, Maxillary displacement.
Superimposition is along the basion-nasion at nasion.

made for the patient 14 months after the onset of treatment. in midfacial length, which is greater than normal, as well as
The total treatment time was 2 years3 months with the patient a 7-mm increase in mandibular length, a growth increment
wearing the appliance on an 18 to 20-hour-a-day basisduring within normal limits. Lower anterior facial height, which
that time. usually increases1 mm per year,*Oincreasedby 6 mm. The
position of the upper incisors was relatively unchanged an-
Analysis of traatment results teroposteriorly, whereas the lower incisors became slightly
During the 2Y2years between the first film (Fig. 12, A) more protrusive relative to the A-pogonion line.
and the secondfilm (Fig. 12, B), there was a 7 mm-increase There was no change in the mandibular plane angle which
422 McNamara and Huge

Flg. 13. Case III cephalometric tracings. A, Tracing of initial lateral cephalogram. B, Tracing of the
cephalogram taken 21 months later. -

remained at 23, but there was a decreaseof 2 in the facial be expected during normal growth. In addition, the vector of
axis angle. mandibular growth was redirected more vertically with little
Cranial base superimposition ( Fig. 12, C) . Superimpos- anterior chin movement relative to cranial base structures.
ing along the basion-nasion line at its intersection with the
CASE III
pterygomaxillary fissure indicated that, as observed in Case
I, the direction of mandibular growth was redirected verti- This patient, a boy aged 6 years 8 months, had a Class
cally. There was no change in the mandibular plane angle, III malocclusioncharacterizedby a developing anterior cross-
although there was an opening of the facial axis angle. bite. Analysis of the initial head film (Fig. 13, A) showed a
The maxilla was displaced anteriorly with some vertical maxilia that was4 mm in a posterior position relative to cranial
movement observed as well. The anterior crossbitewas cor- base structures. The midfacial length was 77 mm. An ideal-
rected during the treatment period by a greater forward move- ized midfacial length of 81 mm (adding 4 mm to the actual
ment of the maxillary incisors than the mandibular incisors. midfacial length) indicated that effective mandibular length
Changes in the soft-tissueprofile were also observed. in this patient should be 97 to 100 mm. The patients actual
Mandibular superimposition (Fig. 12, D). Superimpos- mandibular length was 98 mm, indicating no major discrep-
ing on the internal structures of the mandible showed an ancy if the maxilla were in a normal position.
upward and slightly backward direction of condylar growth The patient also presented with a slightly short lower
and some remodeling in the area of the symphysis. Mostly anterior facial height (56 m) that was 1 to 2 mm less than
upward movement of the lower molars and lower incisors ideal values.
was noted.
Treatment progress
Maxillary superimposition ( Fig. 12, E) . Superimposing
on the internal structuresof the maxilla revealedless forward The patient wore the appliance on a full-time basis for
movement of the upper teeth than was observed in the patient approximately 18 months during which time the occlusaldis-
in Case I. However, the maxillary incisors and molars did crepancieswere corrected.
move in a downward and forward direction relative to the
Analysis of treatment results
maxilla.
Maxillary displacement (Fig. 12, F) Superimposition of When the initial head film (Fig. 13, A) was compared
the serial tracings along the basion-nasion line at nasion in- with the posttreatment head film (Fig. 13, B) taken 21 months
dicated that there was no forward maxillary displacement later, significant skeletal and dental adaptations could be ob-
relative to nasion during treatment. The palate descendedin served. Maxillary length increasedby 3 mm-a value within
a downward manner as occurs during normal growth. 0,11 normal limits. Mandibular length increased4 mm and lower
anterior facial height increasedby 2 mm; again values were
Summary within normal limits.
This patient showed an increasein midfacial length and The mandibular plane angle decreasedby 1 as did the
an increase in lower anterior facial height over what would facial axis angle.
Volume 88 Functional regulator (FR-3) of Friinkel 423
Number 5

Fig. 13. (Contd). Case III cephalometric tracings. C, Superimposition of the tracings seen in A and
B along the basion-nasion line at the pterygomaxillaty fissure. D, Mandibular superimposition on internal
structures. E, Maxillary superimposition on internal structures. F, Maxillary displacement. Superim-
position is along the basion-nasion line at nasion.

Slight alterations were observed in the position of the Mandibular superimposition (Fig. 13, D). Superimpos-
posterior teeth; the attainment of a Class I molar relationship ing on the internal structuresindicated that there was some
was noted. The potential anterior crossbitewas also averted superior growth at the head of the condyle and slight remod-
primarily due to the downward and forward movement of the eling in the gonial region. The positions of the lower incisors
upper incisors. and lower molars were relatively unchanged.
Cranial base superimposition (Fig. 13, C). Superimpos- Maxillary superimposition (Fig. 13, E) . Superimposing
ing along the basion-nasion line at nasion indicated that once on the internal structuresof the maxilla indicated that some
again mandibular growth was redirected inferiorly with a remodeling had occurred in this area, particularly along the
slight opening of the facial axis angle. The maxilla moved in labial and lingual surfacesof tire upper incisors. Someforward
a downward and slightly forward direction. and slightly downward movement of the upper molars was
The largest change in tooth position was observed in the also observed.
upper molar region. Little change in the contour of the soft- Maxillary displacement (Fig. 13, F). Superimposing
tissue profile was noted. along the basion-nasionline at nasion showed that the maxilla
424 McNamara and Huge

descended in a downward fashion relative to nasion. Little Illustrations were provided by Mr. William L. Brudon and
change in the anteroposterior position of this bone was noted. Mr. Eugene E. Leppanen.

Summary
REFERENCES
Much less skeletal change was observed in this patient 1. Fr;inkel R: Technik und Handhabung der Funktionsregler VEB
than in the patients in Cases I and II. The maxilla moved Verlag Volk und Gesundheit, Berlin, 1976.
downward and forward; the mandible was redirectedin a more 2. Frankel R: Biomechanical aspects of the form/function relation-
inferior direction. The major dental change appears to have ship in craniofacial morphogenesis: A clinicians approach. In
been caused, at least in part, by a downward and forward McNama.ra JA Jr, Ribbens KA, Howe RP (editors): Clinical
alterations of the growing face, Monograph 14, Craniofacial
movement of the upper dentition.
Growth Series, Ann Arbor, 1983, Center for Human Growth
and Development, The University of Michigan.
SUMMARY AND CONCLUSIONS
3. Frtikel R: Maxillary retrusion in Class III and treatment with
The purpose of this article has been to describe the the function corrector III. Trans Eur Orthod Sot 46: 249-259,
clinical use of the FR-3 appliance of Frtinkel, which 1970.
4. Eirew HL, McDowell F, Phillips JG: The functional regulator
has classically been used in cases of Class III maloc-
of Fr;inkel. Br J Otthod 3: 67-74, 1976.
clusion. The parts of the appliance have been described 5. Petit H: Adaptations following accelerated facial-mask therapy.
as have the method of impression taking, bite registra- In McNamara JA Jr, Ribbens KA, Howe RP (editors): Clinical
tion, construction, and appliance delivery. alterations of the growing face, Monograph 14, Craniofacial
The three case reports, each of which demonstrated Growth Series, Ann Arbor, 1983, Center for Human Growth
and Development, The University of Michigan.
a slightly different morphologic type, indicate that this
6. Eirew HL: Personal communication, 1984.
appliance has a different effect on the growing cranio- 7. McNamara JA Jr, Huge SA: The Frlnkel appliance Fr-2: Model
facial skeleton. The two common findings that were preparation and appliance construction. AM J ORWO~ 80: 478-
observed in all three patients were the forward move- 495, 1981.
ment of the maxillary dentition and the redirection of 8. Harvold EP: The activator in interceptive orthodontics. The
C. V. Mosby Company, St. Louis, 1974.
mandibular growth in a vertical direction. Variable re-
9. McNamara JA Jr: The Frtiel appliance: Clinical management.
sponses in the maxilla were noted. J Clin Orthod 16: 390-407, 1982.
Before any precise statement can be made regarding 10. McNamara JA Jr: A method of cephalometric evaluation. AM J
the mechanism of action of the Frgnkel FR-3 appliance, ORTHOD 86: 449-469, 1984.
appropriate prospective clinical trials must be carried 11. Ricketts RM: The influence of orthodontic treatment on facial
growth and development. Angle Orthod 30: 103-133, 1960.
out in Class III patients presenting with a wide variety
of morphologic types. Reprint requests to:
Dr. James A. McNamara
The authors wish to acknowledge the help provided by Department of Orthodontics
Professor Dr. Rolf Ft%nkel in the preparation of this manu- School of Dentistry
script. We also thank Dr. Raymond P. Howe and Dr. Hans The University of Michigan
L. Eirew for their critical review and helpful suggestions. Ann Arbor, Ml 48109